Methods, compositions and kits for surgical repair

ABSTRACT

In some aspects, the present invention provides surgical procedures that comprise applying compositions into and/or onto tissue, including supporting tissues (e.g., ligaments, connective tissue, muscles, etc.) for pelvic organs, among other tissues. In other aspects, the present disclosure pertains to compositions that are useful for performing such procedures. In still other aspects, the present disclosure pertains to kits that are useful for performing such procedures.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a Continuation of, and claims priority to, U.S.patent application Ser. No. 14/138,733, filed on Dec. 23, 2013, now U.S.Pat. No. 9,682,177, entitled “METHODS,COMPOSITIONS AND KITS FOR SURGICALREPAIR”, which, in turn, claims priority to U.S. Patent Application No.61/746,711, filed on Dec. 28, 2012, entitled “METHODS,COMPOSITIONS ANDKITS FOR SURGICAL REPAIR”, the disclosures of which are incorporated byreference herein in their entirety.

FIELD OF THE INVENTION

The present invention relates to procedures, compositions and kitspertaining to surgical repair.

BACKGROUND OF THE INVENTION

Medical surgical procedures are known in which various ligaments,connective tissue, muscles and organs of the body are repaired.

As a specific example, common surgical repairs for pelvic organ prolapse(POP) include those whereby biologic or synthetic grafts are used toprovide support for the prolapsed organs. Currently available graftmaterials can be less than ideal for this purpose. For example, biologicgrafts commonly lack ability to provide the required strength for organsupport, although they are better integrated with tissue than syntheticgrafts. Synthetic meshes may result in complications such as mesherosion, dyspareunia, and infection. In either type of repair, theligaments originally used to hold the vagina and uterus are often tooweak for use in organ repair (e.g., re-suspension of the vaginal apex).Instead, alternative ligaments such as sacrospinous ligament (whichextends from the sacrum to its insertion on the ischial spine) are usedto attach the new grafts. The consequences of this approach include (1)an altered anatomic position of the affected organs and (2) alteredtissue biomechanics that occur due to increased tension between theorgan(s) and the non-native ligaments (now connected by a foreignmaterial with biomechanical properties different than native tissue).

Deficiencies in these and other surgical procedures may be addressedusing the procedures, compositions and kits described herein.

SUMMARY OF THE INVENTION

In some aspects, the present invention provides surgical procedures thatcomprise applying compositions into and/or onto tissue, includingsupporting tissues (e.g., ligaments, connective tissue, muscles, etc.)for pelvic organs, among other tissues.

In other aspects, the present invention pertains to compositions thatare useful for performing such procedures, among others.

In still other aspects, the present invention pertains to kits that areuseful for performing such procedures, among others.

These and various additional aspects, embodiments and advantages of thepresent invention will become immediately apparent to those of ordinaryskill in the art upon review of the Detailed Description and anyappended claims to follow.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic cross-sectional view of a portion of the femaleanatomy.

FIGS. 2-5 are flow charts schematically illustrating various methods inaccordance with the invention.

DETAILED DESCRIPTION

The present disclosure pertains to compositions, kits and methods ofincreasing tissue strength, including promoting tissue regenerationand/or remodeling in tissues, such as supporting tissues (e.g.,ligaments, connective tissue, muscles, etc.) for pelvic organs, amongothers.

In accordance with one aspect, suitable compositions are injected into,applied onto or attached to support tissues of interest. For instance,as described in more detail below, one of the following procedures, or acombination of any two or all three of the following procedures, may beperformed: (a) a suitable composition (e.g., a hydrogel, plug, etc.) maybe injected into support tissue (e.g., a native ligament such as auterosacral ligament, etc.) to promote remodeling of the supportstructure, another suitable composition (e.g., solid or solidifiablepolymeric composition, etc.) may be applied onto the surface of thesupport tissue to temporarily or permanently increase the strength ofthe support tissue, and a further suitable composition (e.g., a graft)may be attached to the support tissue and also to another structure inthe body (e.g., the vaginal apex, etc.).

Compositions may be injected into, applied onto or attached to supporttissues of interest by one or more of the following routes, amongothers: via open abdominal surgery (laparotomy), laparoscopically,transvaginally (e.g., by vaginal incision), transrectally,transcystoscopically or percutaneously.

In some embodiments, a suitable solid or solidifiable composition isapplied to the surface of a tissue of interest using a suitableapplication technique. For example, a suitable solid composition (e.g.,in the form of a sheet or strip) may be attached or adhered to thetissue or a suitable solidifiable fluid composition may be applied ontothe surface of the tissue, for example, by spraying, brushing, rolling,extruding or another suitable technique.

In some embodiments, a suitable composition is injected into tissue ofinterest such that an implant (e.g., a hydrogel implant or polymercomposition implant) is formed in the tissue of interest. Thecomposition may be injected at a single site, or in multiple sites asneeded. For example, a hydrogel composition can be pre-formed ex vivoand injected into the tissue of interest, or a hydrogel precursor can beinjected into the tissue of interest which subsequently forms a hydrogelcomposition in vivo, among other techniques. The hydrogel implant thatis formed in the tissue promotes tissue regeneration and/or remodeling,leading to an increase in biomechanical strength of the tissue.

In some embodiments, a solid composition is injected into the tissue.

For example, one or more solid plugs containing tissue growth factorsand/or other therapeutic agent can be injected into the tissue. Theplug(s) may be injected at a single site, or in multiple sites asneeded. The shape of the plug(s) may be varied. For example, the plug(s)may be in the form of one or more sharpened plugs which can be injectedinto the tissue (e.g., via a push rod or in the form of darts which canbe injected into tissue, for example, by propelling the darts from asuitable device) or in the form of one or more fibers (which could, forexample, be aligned in the tissue to direct tissue regrowth). Plugshapes include pellets, beads, cylinders or tubes, among others. Theplugs can be any suitable size, e.g., from nanotube size to severalmillimeters in length and/or width as appropriate for the best repair.For example, the plugs may have a length and a width selected,independently, from sizes ranging 1 nm to 10 nm to 100 nm to 1 μm to 10μm to 100 μm to 500 μm to 1 mm to 5 mm to 10 mm, among other values.

As used herein the term “hydrogel composition” embraces both preformedhydrogel compositions and hydrogel precursor compositions.

An “injectable” composition is a fluid, solidifiable or solid (e.g.,plug) composition that can be delivered by injection (e.g., through aneedle under pressure exerted using a syringe, via a push rod, propelledfrom suitable device, etc.).

A “solidifiable” composition is a composition that can be applied to asurface or below the surface in fluid form whereupon it solidifiesthrough active or passive means into a solid material.

For ease of reference, a schematic cross-sectional view of a femalehuman anatomy is shown in FIG. 1 and shows the bladder, rectum, uterusand urethra 130. Also shown are the vaginal epithelium 122 as well asthe anterior vaginal wall 124 a (pubocervical fascia) and the posteriorvaginal wall 124 p (rectovaginal fascia), which are part of the vaginalsupport structure. The two uterosacral ligaments (USLs) 110 are alsoshown, which are present on each side of the uterus and extend from theuterine cervix to the sacrum, serving to support the uterus and hold itin place.

In some embodiments, a suitable composition is applied onto and/orinjected into native tissue (e.g., the USLs, the uterus in the areaswhere the USLs attach to the uterus, etc.) in order to increase tissuestrength thereby preventing or retarding POP without the need for organremoval (e.g., removal of the uterus).

In other embodiments, a suitable composition is applied onto and/orinjected into native tissue that is retained after organ removal (e.g.,after uterus removal in a hysterectomy procedure) in order to increasetissue strength and improve the likelihood of success in the procedure.

For example, in patients where it is desired to attach the USLs to thevagina during a vaginal vault suspension procedure after hysterectomy, asuitable composition may be applied onto and/or injected into the USL,the vaginal support structure, or both. The support structure at theapex of the vagina includes the pubocervical fascia (anterior vaginalwall) and the rectovaginal fascia (posterior vaginal wall).

In specific embodiments, an injection device may be inserted through aworking channel of a laparoscope, hysteroscope, cystoscope or othersuitable endoscopic device for visual guidance, and a suitablecomposition injected at multiple points (e.g., multiple evenly spacedpoints) along each USL ligament. If desired, the composition may also beinjected at multiple points (e.g., multiple evenly spaced points) alongthe anterior and posterior walls transvaginally (e.g., using the sameinjection device).

Injection devices for use in the present disclosure may comprise, forexample, a proximal syringe, an elongated tube (catheter) and a distalneedle, preferably with the syringe and needle engaging the cathetertube via suitable fittings (e.g., Luer fittings, etc.). In someembodiments, the injection device comprises an array of needles,allowing multiple sites to be injected simultaneously. In someembodiments, multiple injection devices may be employed. Beneficialneedle sizes include 15-28 gauge needles (e.g., 15 to 16 to 17 to 18 to19 to 20 to 21 to 22 to 23 to 24 to 25 to 26 to 27 to 28 gauge), moretypically 20 to 25 gauge needles.

In specific embodiments, an application device may be inserted through aworking channel of a laparoscope, hysteroscope, cystoscope or othersuitable endoscopic device for visual guidance, and a suitablecomposition applied to the each USL ligament. If desired, thecomposition may be also applied to the anterior and posterior vaginalwalls. For example, a suitable solid composition (e.g., in the form of asheet or strip) may be attached to the tissue using a suitable couplingmaterial such as a biodegradable or nonbiodegradable staple,biodegradable or nonbiodegradable suture or biodegradable ornonbiodegradable adhesive, among others. Alternatively, one or moresolidifiable fluid compositions may be applied onto the tissue, forexample, using a brush or roller or spray device, or dripped onto thesurface or delivered through a catheter tube (e.g., via a proximaldelivery device such as a syringe which may be coupled to the cathetertube via a suitable fitting such as a Luer fitting, etc.).

In some embodiments, illustrated schematically in FIG. 2, suitablecompositions may be applied onto and/or injected into tissue (e.g., USL,vaginal tissue, or both) at a point in time before POP procedure (e.g.,before hysterectomy and vaginal vault suspension) that is sufficient toallow the tissue to regenerate by the time of the procedure.

In other embodiments, illustrated schematically in FIG. 3, suitablecompositions may be applied onto and/or injected into tissue (e.g., USL,vaginal tissue, or both) at the time of the POP procedure (e.g.,immediately prior to a procedure combining hysterectomy and vaginalvault suspension), with tissue regeneration occurring subsequent to theprocedure.

In other embodiments, suitable compositions may be applied onto and/orinjected into tissue (e.g., USL, vaginal tissue, or both) at the time ofthe hysterectomy (e.g., immediately prior to uterus removal). Then, thetissue is left to regenerate/remodel and the wounds are allowed to healfor a time after the hysterectomy. If ligament repositioning is needed,a second surgery may be performed. For example, a USL suspension may beperformed, during which the USL ligaments are sutured directly orindirectly to the vaginal walls to re-suspend the vagina. Suchprocedures are illustrated schematically in FIG. 4.

In certain cases, supporting tissue (e.g., ligaments, connective tissue,muscles, etc.) may be too damaged or torn for direct attachment to otherliving tissue. For example, the USLs may be too damaged or torn fordirect attachment to vaginal tissue in a USL suspension procedure. Insuch cases, in addition to applying a suitable composition onto and/orinjecting a suitable composition into the USLs, grafts (e.g., asynthetic graft, biologic graft or a combination synthetic/biologicgraft) may be attached to the USLs.

For instance, suitable compositions may be applied onto and/or injectedinto the USLs before, during or after removal of the uterus, and a graftmay be attached to the USLs after removal of the uterus and before orafter the introduction of the composition. This procedure is illustratedschematically in FIG. 5. In a particular instance, a suitablecomposition may be applied onto and/or injected into the USLs prior toremoval of the uterus, and a graft may be attached to the USLs afterremoval of the uterus.

The graft may be attached to the USLs, for instance, by stapling (e.g.,using biostable or bioabsorbable staples), suturing (e.g., usingbiostable or bioabsorbable sutures) or by use of a suitable biostable orbiodegradable tissue adhesive.

The grafts may then be attached to vaginal tissue, either immediately,or after a period of healing and remodeling (i.e., during a secondsurgery). In one particular embodiment, a biologic graft is stapled,sutured or glued onto the USL ligaments and the two ligaments areconnected by a synthetic graft material in the middle which is cut atthe time of uterosacral ligament suspension procedure.

As previously indicated, visualization may be achieved during theprocedures described herein using various devices, for example, using alaparoscope, hysteroscope, cystoscope or other suitable endoscope.Alternatively, a combination of two visualization devices may be used(e.g., an abdominally inserted laparoscope and a transvaginally insertedendoscope) to ensure appropriate visualization and access to USLs.

The injectable compositions, the solid or solidifiable compositions forapplication onto or into tissue, and/or the grafts described herein maycontain suitable imaging agents as discussed below. For example, abiocompatible dye (e.g., fluorescent dye, colorimetric dye, etc.) may beemployed in the injectable compositions to ensure that the injectionsites are readily visualized during the procedure. A biocompatible dyemay also be employed in solid or solidifiable compositions suitable forapplication onto or into tissue to ensure that the areas of applicationare readily visualized. A biocompatible dye may also be used to mark thegraft material that is employed, if any. Where a fluorescent dye isemployed, a scope (e.g., endoscope, laparoscope, etc.) may be used as aconduit for an optical fiber connected to a fluorescence optical system.As another example, injectable compositions, solid or solidifiablecompositions suitable for application onto or into tissue, and/or graftsmay also contain radiopaque agents to enable visualization via x-rayradiation. Such agents include barium sulphate, bismuth compounds, ortungsten, among others. The loading of such agents will be controlled tomaximize contrast, while maintaining appropriate physical properties.For example, loadings of up to 20 or 30% by volume may be optimal,although for more dense agents, such as tungsten, the loading may beonly 5% by volume.

In some embodiments, it is desirable to match the physical properties ofthe graft material and/or solid/solidified material with the physicalproperties of the USLs (e.g., the Young's modulus may be matched) toprovide for more normal load bearing and to help stimulate proper cellgrowth and remodeling, for example, stimulation of fibroblasts togenerate collagen, and proper conversion of collagen III to collagen I.The Young's modulus of the or solid/solidified material and grafts mayrange, for example, from 50 kPA to 1000 kPA (e.g., 50 kPA to 75 kPA to100 kPA to 200 kPA to 300 kPA to 400 kPA to 500 kPA to 750 kPA to 1000kPa), preferably, 400 kPA to 500 kPA in some embodiments.

As defined herein, a “biologic” material is a material that comprisesone or more extracellular matrix components. Biologic materials for usein the grafts described herein include crosslinked and non-crosslinkedallograft (e.g., human cadaveric) materials, as well as crosslinked andnon-crosslinked heterograft (e.g., bovine, porcine, equine, etc.)materials. Specific examples of non-crosslinked biologic materialsinclude mammalian non-crosslinked biologic matrix materials, such ashuman dermis, human fascia lata, fetal bovine dermis and porcine smallintestinal submucosa. Specific examples of crosslinked biologicmaterials include mammalian crosslinked biologic materials such ascrosslinked porcine dermis, crosslinked porcine small intestinalsubmucosa, crosslinked bovine pericardium, and crosslinked horsepericardium. Such materials are typically acellular. Moreover, they aretypically predominantly formed of collagen.

Synthetic materials for use in the grafts described herein may beselected from biostable synthetic polymers, biodegradable syntheticpolymers and combinations of biostable and biodegradable syntheticpolymers.

As used herein, “polymers” are molecules that contain multiple copies ofone or more types of constitutional species, commonly referred to asmonomers. The number of monomers within a given polymer for use hereinmay vary widely, ranging, for example, from 2 to 5 to 10 to 25 to 50 to100 to 1000 to 10,000 or more constitutional units. As used herein, theterm “monomer” may refer to the free monomers and those that areincorporated into polymers (also referred to herein as monomer“residues”), with the distinction being clear from the context in whichthe term is used.

As used herein, “oligomers” are small polymers containing from 2 to 5monomers.

Biostable synthetic polymers may be selected, for example, from thefollowing, among others: (a) polyolefin homopolymers and copolymers,including homopolymers and copolymers of C2-C8 alkenes, for example,polyethylene and polypropylene among others, (b) fluoropolymers,including homopolymers and copolymers of C2-C8 alkenes in which one ormore hydrogen atoms are substituted with fluorine, for example,polytetrafluoroethylene (PTFE), polyvinylidene fluoride (PVDF),poly(vinylidene fluoride-co-hexafluoropropene) (PVDF-HFP) among others,(c) polyamides such as nylons, among others, (d) polyesters, including,for example, polyethylene terephthalate, among others, (e) polyurethanessuch as polyisobutylene based polyurethanes (PIB-PU) that comprise oneor more polyisobutylene segments, among others, (f) polyoxyalkylenesincluding homopolymers of trioxane (polytrioxane, also known aspolyoxymethylene or acetal) and copolymers of trioxane (e.g., copolymersof trioxane and dioxane), (g) styrenic copolymers such as alkene-styrenecopolymers, including block copolymers comprising one or morepolystyrene blocks and one or more polyalkene blocks, for instance,poly(styrene-b-isobutylene-b-styrene) (SIBS),poly(styrene-b-ethylene/butylene-b-styrene) (SEBS) among others, and (h)as well as various other polymers and copolymers (including blockcopolymers).

Biodegradable synthetic polymers may be selected, for example, frompolyesters and polyanhydrides, among others. Specific biodegradablepolymers may be selected from suitable members of the following, amongothers: (a) polyester homopolymers and copolymers (including polyestersand poly[ester-amides]), such as polyglycolide, polylactide (PLA),including poly-L-lactide, poly-D-lactide, and poly-D,L-lactide,poly(lactide-co-glycolide) (PLG), includingpoly(L-lactide-co-glycolide), poly(D-lactide-co-glycolide) andpoly(D,L-lactide-co-glycolide), poly(beta-hydroxybutyrate),poly-D-gluconate, poly-L-gluconate, poly-D,L-gluconate,poly(epsilon-caprolactone), poly(delta-valerolactone),poly(p-dioxanone), poly(trimethylene carbonate),poly(lactide-co-delta-valerolactone),poly(lactide-co-epsilon-caprolactone), poly(lactide-co-beta-malic acid),poly(lactide-co-trimethylene carbonate), poly(glycolide-co-trimethylenecarbonate), poly(beta-hydroxybutyrate-co-beta-hydroxyvalerate),poly[1,3-bis(p-carboxyphenoxy)propane-co-sebacic acid], poly(sebacicacid-co-fumaric acid), and poly(ortho esters) such as those synthesizedby copolymerization of various diketene acetals and diols, among others;and (b) polyanhydride homopolymers and copolymers such as poly(adipicanhydride), poly(suberic anhydride), poly(sebacic anhydride),poly(dodecanedioic anhydride), poly(maleic anhydride),poly[1,3-bis(p-carboxyphenoxy)methane anhydride], andpoly[alpha,omega-bis(p-carboxyphenoxy)alkane anhydrides] such aspoly[1,3-bis(p-carboxyphenoxy)propane anhydride] andpoly[1,6-bis(p-carboxyphenoxy)hexane anhydride], among others.

Where a biodegradable polyester is used (e.g., PLA, PLG, etc.), one ormore soft blocks, for example, polyethylene oxide (PEO),poly(trimethylene carbonate) (PTMC), poly(dioxane-2-one) (PPDO) orpolycaprolactone (PCL) blocks, among others, may be included with one ormore polyester blocks in the polymer to vary hardness, elongation, anddegradation rate of the polymer. Examples include diblock and triblockcopolymers such as PLA-PCL, PLA-PCL-PLA, PLG-PCL, PLG-PCL-PLG, PLA-PEO,PLA-PEO-PLA, PLG-PEO, PLG-PEO-PLG, PCL-PLA-PTMC, PLA-PTMC-PCL andPLA-PTMC-PPDO, among others.

Where copolymers are employed, copolymers with a variety of monomerratios may be available. For example, where isobutylene-styrenecopolymers (e.g., SIBS) are used, the ratio of monomers in thesepolymers can be selected to obtain mechanical properties such thattissue compatibility is enhanced. For instance, a higher isobutylenecontent will result in a softer polymer that may be a better match forthe durometer of the surrounding tissue. As another example, where PLGis used, a variety of lactide:glycolide molar ratios will find useherein, and the ratio is largely a matter of choice, depending in parton the rate of degradation desired. For instance, a 50:50 PLG polymer,containing 50% D,L-lactide and 50% glycolide, will provide a fasterresorbing copolymer, while 75:25 PLG degrades more slowly, and 85:15 and90:10, even more slowly, due to the increased lactide component.Degradation rate can also be controlled by such factors as polymermolecular weight and polymer crystallinity. More broadly, where used,PLG copolymers include those having a lactide/glycolide molar ratioranging, for example, from 10:90 or less to 15:85 to 20:80 to 25:75 to40:60 to 45:55 to 50:50 to 55:45 to 60:40 to 75:25 to 80:20 to 85:15 to90:10 or more.

In some cases, it may be desirable to support the vagina for a periodafter a surgical procedure is performed (e.g., 2-4 weeks) to promotehealing. For instance, vaginal support device such as a biostable orbiodegradable pessary may be inserted into the vagina for this purpose.A suitable pessary may be selected from a variety of vaginal pessarydesigns known in the obstetrics/gynecology art including ring pessaries(with or without knob), Shaatz pessaries, dish pessaries, ovalpessaries, Gehrung pessaries, Gellhorn pessaries, Hodge pessaries,Risser pessaries, Smith pessaries, cube pessaries, cup pessaries, donutpessaries, and Marland pessaries, among others.

Inflatable devices may also be used to support the vagina after surgery.Inflatable devices may serve to provide a mechanical stimulus thatpromotes tissue regeneration. For instance, continuous expansion andcontraction of a compliant balloon-inflatable device may allow tissue tobe stretched and contracted during healing so that the tissue remodelsappropriately. Some specific examples of suitable inflatable devicesinclude inflatable pessary devices such as those described in U.S. Pat.No. 5,611,768 to Tutrone, Jr., U.S. Pat. No. 6,470,890 to Diokno et al.,and Publication No. US 2009/0216071 to Zipper.

In other embodiments, a vaginal cap (e.g., a cap of hemispherical orother suitable geometry) may be applied to the vaginal apex to maintainthe shape of the vaginal apex during healing. Such a cap may be held inplace on the interior or exterior or the vaginal apex, for example, viaa biodegradable adhesive, staple or suture. Such a cap may be formed,for example, from a suitable biodegradable and biostable material. Forinstance, a suitable biologic material, biostable synthetic polymer orbiodegradable synthetic polymer selected from those described above maybe employed.

As indicated above, compositions may be applied onto the surface ofsupport tissue (e.g., ligaments, connective tissue, muscle, etc.) insolid or solidifiable form to temporarily improve (e.g., in the case ofbiodegradable compositions) or permanently improve (e.g., in the case ofbiostable compositions) the biomechanical strength of the tissue. Forexample, in some embodiments, a suitable composition in solid form maybe contacted with the tissue and, if desired, secured in place, forinstance, by a staple, suture or a suitable adhesive. In certainbeneficial embodiments, the solid composition is microtextured toaccommodate protein adhesion. In further embodiments, a solidifiablecomposition is applied onto the tissue in a fluid form, which solidifiesafter application onto the tissue, for example, due to removal ofsolvent from the composition or chemical curing (e.g., crosslinking) ofthe composition, among other mechanisms.

Compositions may also be injected into support tissue (e.g., ligaments,connective tissue, muscle, etc.) in solid or solidifiable form topromote tissue regeneration and/or remodeling in tissues. For example,in some embodiments, a suitable solid composition is injected intotissue in the form of a plug. As another example, in some embodiments, asuitable solidifiable composition is injected into the tissue in a fluidform, which solidifies after injection into the tissue, for example, dueto removal of solvent from the composition or chemical curing (e.g.,crosslinking) of the composition, among other mechanisms.

Solid and solidifiable compositions for application onto or into tissueinclude both biodegradable and biostable materials. For instance, insome embodiments, such solid and solidifiable compositions may containone or more suitable biologic materials, biostable synthetic polymers orbiodegradable synthetic polymers selected from those described above,among others.

In some embodiments, a suitable curable material such as a radiationcurable material (e.g., a material curable with ionizing or non-ionizingradiation including e-beam radiation, gamma radiation, visible light, UVlight, etc.) may be employed as a solidifiable composition. For example,radiation hydrogel curable hydrogel precursors such as those describedbelow, among others, may be applied to tissue and cured. In someembodiments, a biodegradable or biostable synthetic adhesive (e.g., acyanoacrylate adhesive, etc.), a biologically derived adhesive (e.g., atwo-part fibrin glue), a moisture activated fibrin based powder, dextranbased adhesive, serum albumin based adhesive, or other medical adhesivesknown to those in the art may be employed. One specific example, of aradiation curable material is a photopolymerized gelatin as described inas described in Elvin et al., “A highly elastic tissue sealant based onphotopolymerised gelatin,” Biomaterials 31 8323-8331 (2010).

As previously noted, in various embodiments, hydrogel compositions arebeneficial for use as injectable compositions in accordance with thepresent disclosure and include both injectable preformed hydrogelcompositions and injectable hydrogel precursor compositions.

As used herein, a “hydrogel” is a three-dimensional, crosslinked networkcomprising hydrophilic polymers that contain a substantial amount ofwater. A hydrogel may contain, for example, from 30 wt % to 40 wt % to50 wt % to 60 wt % to 70 wt % to 80 wt % to 90 wt % to 95 wt %, or more,water on a w/w basis. A “hydrogel precursor” is a hydrophilic polymer(which may be an oligomer or a larger polymer) that is capable ofbecoming crosslinked to form a hydrogel.

Hydrogels may be physically crosslinked, chemically crosslinked, orboth. Physically crosslinked hydrogels are formed by non-covalentinteractions such as van der Waals forces, hydrophobic interactions,and/or electrostatic interactions (e.g., charge-charge interactions,charge-dipole interactions, and dipole-dipole interactions, includinghydrogen bonding). Chemically crosslinked hydrogels are formed throughcovalent bonds.

Hydrogel precursors may become physically or chemically crosslinked invivo in response to changes in various conditions, includingtemperature, pH and ionic strength or upon exposure to stimuli such asradiation (e.g., ionizing or non-ionizing radiation including e-beamradiation, gamma radiation, visible light, UV light, etc.) and magneticfields. Thus, physical crosslinking commonly arises from self-assemblyunder stimuli that do not lead to covalent bond formation, includingchanges in temperature, pH, ion concentration, and hydrophobicinteractions, among others. Chemical cross-linking may be obtained viaphoto-initiated, redox-initiated or Michael-type addition polymerizationreactions, among others.

In some embodiments, a hydrogel may be formed (e.g., crosslinked) exvivo and used to create a hydrogel composition which is introduced intothe tissue of a subject. In such embodiments, the hydrogel compositionmay be further treated (e.g., by shearing, grinding, etc.) to provide asuitable injection consistency.

In other embodiments, a hydrogel precursor composition may be introducedinto the tissue of a subject and crosslinked in vivo.

Hydrogels can be made from virtually any hydrophilic polymer. Hydrogelsfor use in the present invention thus include hydrogels formed fromhydrophilic natural polymers, such as hydrophilic amino-acid-basedpolymers, including peptides (i.e., amino-acid polymers typicallycontaining from 2 to 50 amino acids), proteins (i.e., amino-acidpolymers typically containing more than 50 amino acids), andpolyaspartamide, as well as polysaccharides, for instance, collagen,gelatin, fibrin, albumin, hyaluronic acid, glycosaminoglycans, alginates(including alginic acid and its derivatives), agarose, chitosan,cellulosic polymers such as carboxymethyl cellulose, starches includinghydroxyethyl starch and dextran polymers including dextran andcarboxymethyl dextran, among others. Hydrogels for use in the presentinvention also include hydrogels formed from hydrophilic syntheticpolymers, for example, selected from polyethers including polyalkyleneoxides such as polyethylene oxide (also referred to as polyethyleneglycol), polypropylene oxide and polyethylene glycol-co-polybutyleneterephthalate, polyols such as polyvinyl alcohol, polyacids such aspolyacrylic acid, polymethacrylic acid and derivatives thereof,including polyacrylates, polymethacrylates such as poly(2-hydroxyethylmethacrylate) (which is also a polyol) and polyacrylamides includingpoly(N-isopropylacrylamide), polyamines, hydrolyzed polyacrylonitrile,poly(vinyl pyrrolidone), polyphosphazene, hydrophilic polyurethanes andsynthetic hydrophilic polypeptides (e.g., polymers and copolymers ofhydrophilic amino acids such as arginine, lysine, asparagine, glutamicacid, aspartic acid, and proline), among others.

In addition to water and polymer, hydrogel compositions in accordancewith the invention may optionally include additional agents, as desired,including crosslinking species, therapeutic agents, imaging agents,tonicity adjusting agents, hydrogel particle suspension agents,biologically active agents, such as enzymes or peptides, and pHadjusting agents, among others.

Solid and solidifiable compositions for application onto or into tissueand grafts for use in the present disclosure may also containcrosslinking species, therapeutic agents, imaging agents, reinforcingagents, and cells (e.g. stem cells, mesenchymal cells, cells harvestedfrom patient tissue including ligaments and other support tissue, etc.),among others.

Examples of therapeutic agents for use herein include biologic agentsthat stimulate fibroblast activity including proteins such as FOX03A andHox-A11, Lysil oxidase (LOX), proteoglycans, glycosaminoglycans, andgrowth factors such a fibroblast growth factor (FGF), hormones such asestrogen, progesterone, and progesterone diol, and other wound healingagents such as NO-releasing compounds. Examples of NO-releasingcompounds include O-nitroso compounds (e.g., compounds having one ormore —O—NO groups), S-nitroso compounds (e.g., compounds with one ormore —S—NO groups) and N-nitroso compounds (e.g., compounds having an═N—NO group, for instance, compounds having —N—N₂O₂ ⁻ groups, which areknown as N-nonoate compounds). NO-donors may be covalently coupled witha polymer such as poly(vinyl alcohol), among other polymers describedherein.

Examples of imaging agents include (a) fluorescent dyes such asfluorescein, indocyanine green, or fluorescent proteins (e.g. green,blue, cyan fluorescent proteins), (b) contrast agents for use inconjunction with magnetic resonance imaging (MRI), including contrastagents that contain elements with relatively large magnetic moment suchas Gd(III), Mn(II), Fe(III) and compounds (including chelates)containing the same, such as gadolinium ion chelated withdiethylenetriaminepentaacetic acid, (c) contrast agents for use inconjunction with ultrasound imaging, including organic and inorganicechogenic particles (i.e., particles that result in an increase in thereflected ultrasonic energy) or organic and inorganic echolucentparticles (i.e., particles that result in a decrease in the reflectedultrasonic energy), and (d) contrast agents for use in connection withx-ray fluoroscopy, including metals and metal compounds (e.g., metalsalts, metal oxides, etc.), for instance, barium compounds, bismuthcompounds and tungsten, among others, and iodinated compounds, amongothers. As noted above, the loading of such agents will be controlled tomaximize contrast, while maintaining appropriate physical properties.For example, loadings of 5 vol % or less to 30 vol % or more may beemployed (e.g., 5 vol % to 10 vol % to 15 vol % to 20 vol % to 25 vol %to 30 vol %).

If in vivo elution of an imaging agent (e.g., dye) is of concern, theagent may be covalently attached to the compositions described herein,or particles containing the agent may be included in the compositions.In a specific embodiment, microparticles or nanoparticles containing theagent may be attached to parts of the graft, or smaller removable partsof the graft may be employed that contain imaging agents (e.g., enougharea to allow for visualization).

Examples of initiators include photoinitiators (benzoin ethers, arylketones, acyl phosphine oxides, etc.), thermal initiators (as peroxideinitiators, azo initiators, etc.), and redox initiators. Also includedin the formulation can be catalysts, accelerators, hardening agents, andso forth.

Examples of crosslinking species further include, for example,multifunctional crosslinking agents having two or more reactive groups,such as crosslinking agents having two or more sites of unsaturation(e.g., —HC═CH—, —HC═CH₂, —C≡C— or —C≡CH), two or more epoxide groups,two or more glycidyl groups, two or more carboxylic acid groups,di-aldehydes, disulfides, diimidazoles, diimides, and diisocyanates,among others.

An advantage of using hydrogel precursors is that crosslinking (e.g.,photocrosslinking, etc.) may be conducted at the time of administrationor may be postponed to ensure that the newly introduced material hasbeen first accepted by the tissue. In this regard, reports haveindicated that cross-linked collagen grafts result in encapsulation invaginal tissue while non-crosslinked collagen is well integrated (see,e.g., Claerhout et al., “Fate of collagen-based implants used in pelvicfloor surgery: A 2-year follow-up study in a rabbit model,” AmericanJournal of Obstetrics and Gynecology 198 94.e1 (2008)).

To achieve in vivo cross-linking of a photocrosslinkable compositionsuch as a photocrosslinkable hydrogel precursor composition among otherphotocrosslinkable compositions, light can be introduced to the deliverysite (e.g., to the site where the composition is injected or applied),for example, by insertion of a light-transmitting optical fiber througha scope (e.g., a laparoscope or a suitable endoscope positioned in anincision in the vagina, etc.), among other methods.

Where curable compositions (e.g., radiation curable compositionsincluding photocrosslinkable compositions and chemically curablecompositions including moisture curable and two-part systems) areemployed, curing times will vary with the curable composition selectedand may range widely, for example, preferably ranging from 5 seconds to8 hours (e.g., from 5 seconds to 10 seconds to 15 seconds to 30 secondsto 1 minute to 2 minutes to 5 minutes to 10 minutes to 30 minutes to 1hour to 2 hours to 4 hours to 8 hours), more preferably from 10 secondsto 5 minutes.

Examples of tonicity adjusting agents for use in the hydrogelcompositions of the present disclosure include sugars (e.g., dextrose,lactose, etc.), polyhydric alcohols (e.g., glycerol, propylene glycol,mannitol, sorbitol, etc.) and inorganic salts (e.g., potassium chloride,sodium chloride, etc.), among others.

Examples of suspension agents for use in the hydrogel compositions ofthe present disclosure include various surfactants, wetting agents, andpolymers (e.g., albumin, PEO, polyvinyl alcohol, block copolymers,etc.), among others.

Examples of pH adjusting agents for use in the hydrogel compositions ofthe present disclosure include various buffer solutes.

Specific examples of suitable hydrogels for use in the hydrogelcompositions of the present disclosure include hydrogels based onpolyethylene glycol, dextran and/or hyaluronic acid (HA), among others.

For example, U.S. Patent Pub. No. 2010/0055184 to Zeitels et al.,describes polymeric hydrogel comprising a semi-interpenetrating networkof a cross-linked polymer and a water soluble polymer. Water solublepolymers described include polyethylene glycol, poly(lysine), hyaluronicacid, dextran, alginate, gelatin, elastin, collagen, cellulose,methylcellulose, and derivatives thereof. Crosslinked polymers describedinclude cross-linked diacrylate polymers, specifically, cross-linkedpolyethylene glycol diacrylate. Crosslinking is preformed ex vivo usinga UV light (200-400 nm) in the presence of an aryl ketonephotoinitiator, specifically4-(2-hydroxyethoxy)phenyl-(2-hydroxy-2-propyl)ketone (Irgacure 2959).Elastic shear modulus is adjusted by forcing the hydrogel through aseries of needles with smaller and smaller bores.

A hydrogel of this type, specifically, a semi-interpenetrating networkof cross-linked polyethylene glycol diacrylate (PEG-DA) and polyethyleneglycol (PEG) in a 3:7 ratio of PEG-DA to PEG (30 wt % PEG-DA) has beenemployed by Zeitels and others to treat canine vocal cords. See SandeepS. Karajanagi et al., “Assessment of Canine Vocal Fold Function AfterInjection of a New Biomaterial Designed to Treat Phonatory MucosalScarring,” Ann Otol Rhinol Laryngol 2011; 120: 175-184. The material isreferred to by the authors as PEG30.

Another PEG hydrogel, this one based on polyethylene glycol (PEG) andhyaluronic acid (HA), is described in A. T. Hillel et al.,“Photoactivated Composite Biomaterial for Soft Tissue Restoration inRodents and in Humans,” Sci. Transl. Med. 3, 93ra67 (2011). In thiswork, a photo-crosslinkable, injectable hydrogel precursor compositioncomprising PEG-DA, HA and a suitable photoinitiator system (eosin Y) wasinjected into dermal tissue and subsequently subjected to transdermallight exposure to achieve crosslinking See also U.S. Patent Pub. No.2011/0002997 to Elisseeff et al.

An advantage of using a combination of two polymers (e.g., PEGdiacrylate and another water soluble polymer such as PEG or HA, amongothers) in a hydrogel composition is the ability to tune the mechanicalproperties (e.g., elasticity, etc.) within the tissue by varying theratio of the two polymers.

Crosslinked HA hydrogels have also been used in the restoration of vocalfolds. See X. Jia et al., “Hyaluronic acid-based microgels and microgelnetworks for vocal fold regeneration,” Biomacromolecules 7 (2006)3336-44, in which HA microgels were prepared by cross-linking HAderivatives carrying hydrazide (HAADH) and aldehyde (HAALD)functionalities within inverse emulsion droplets; as an alternative,poly(ethylene glycol) dialdehyde (PEGDiALD) was employed in place ofHAALD. Other forms of crosslinked HA hydrogels include auto-crosslinkedHA hydrogels. As described in Davide Renier et al., “Pharmacokineticbehaviour of ACP gel, an autocrosslinked hyaluronan derivative, afterintraperitoneal administration,” Biomaterials 26 (2005) 5368-5374,auto-cross-linked HA derivatives may be obtained through a cross-linkingprocess that results in condensation and, therefore, does not requirebridge molecules. The chemical functions that contribute to thecross-linking process are carboxyl groups, and hydroxyl groups and/oramine groups. The reaction is begun by activating some of the carboxylgroups using a suitable condensing agent followed by nucleophilic attackby the hydroxyl or amine groups, creating an ester-type or amide-typebond which may involve the chain of hyaluronic acid itself(intramolecular crosslink) as well as other chains. Id.

Dextran hydrogels may also be used in the hydrogel compositions of thepresent disclosure. One exemplary hydrogel is a dextran hydrogelprepared at John Hopkins University, known to enhance wound healing andtissue regeneration in deep skin burn injuries with no additional growthfactors, cytokines, or cells. G. Sun et al., “Dextran hydrogel scaffoldsenhance angiogenic responses and promote complete skin regenerationduring burn wound healing” PNAS, Dec. 27, 2011, vol. 108, no. 52,20976-20981.

In addition, polyacrylamide hydrogels may also be used in the hydrogelcompositions of the present disclosure. Polyacrylamide hydrogels havebeen used in restoration of dermal tissue. For example, Aquamid®, fromContura International A/S, Soeborg, Denmark, is an injectable hydrogelcomposition consisting of 97.5% water and 2.5% cross-linkedpolyacrylamide. U.S. Pat. No. 7,790,194, assigned to Contura, describesa polyacrylamide gel manufactured by a polymerization of the monomers ofacrylamide and N,N′-methylene-bis-acrylamide, more specifically, asystem based on acrylamide monomer, N,N′-methylene-bis-acrylamidemonomer (as crosslinker), ammonium persulfate free-radical initiator,and N,N,N′,N′-tetramethylene ethylene diamine (TMED) co-initiator. Theresulting gels are purified and homogenized by grinding.

Gelatin may also be used in the hydrogel compositions of the presentdisclosure. For example, a composition comprising gelatin, rutheniumcatalyst and a persulphate oxidant may be employed in a system analogousto that described in Elvin et al., “A highly elastic tissue sealantbased on photopolymerised gelatin,” Biomaterials 31 8323-8331 (2010).Covalent di-tyrosine crosslinks can be formed by exposure to blue light,either ex vivo or in vivo. As with various other photocrosslinkablecompositions described herein, the hydrogel may be formed ex vivo, or aprecursor composition may be administered and crosslinked in vivo.

In another aspect of the disclosure, kits useful in treating a patientin need of tissue repair are provided. The kits may include all or asubset of all the components useful for treating a patient.

The kits may include, for example, materials compositions that are readyfor application onto or injection into patient tissue. For example, thekits may contain solid materials in the form of sheets or strips forapplication to patient tissue or plugs for injection into patienttissue. The kits may contain one or more containers of a solidifiablematerial (e.g., a material that solidifies upon temperature change,solvent evaporation, crosslinking, etc.) which may be administered ontoor into patient tissue as described herein. The kits may contain one ormore containers of a hydrogel composition that is ready for applicationonto or injection into patient tissue.

The kits may contain one or more containers of material that is used toform an administrable composition ex vivo or in vivo. For example, thekits may contain one or more containers of a composition in dry form(e.g., a hydrogel composition) that is ready for administration uponaddition of a suitable liquid carrier. The kits may contain one or morecontainers of precursor materials (e.g., hydrogel precursor materials),for instance, one or more containers of a crosslinkable composition(e.g., one comprising a multifunctional crosslinkable polymer and/ormonomer) in wet or dry form. The kits may contain one or more containersof hydrogel precursor material in fluid form that may be exposed toradiation (in vivo or ex vivo) to form a hydrogel. The kits may containone or more containers of hydrogel precursor material in dry form whichis first hydrated (e.g., using a suitable carrier) and then exposed toradiation to form a hydrogel. As another example, the kits may containseparate containers of (a) crosslinkable material such as a hydrogelprecursor in wet or dry form and (b) a cross-linking reagent (e.g.,initiator, catalyst, accelerator, etc.) in wet or dry form, or the kitsmay contain separate containers containing components of a two-partcuring system.

The kits may also contain one or more containers of anesthetics,antibiotics, growth factors, and/or other active agents in wet or dryform.

The kits may include one or more containers of a suitable liquid carrier(e.g. sterile water for injection, physiological saline, phosphatebuffer, a solution containing an imaging contrast agent, etc.) which maybe used to reconstitute materials in dry form.

The kits may include a device or receptacle for preparation ofcompositions including hydrogel compositions, for example, a measuringor mixing device.

The kits may include injection devices for administering compositions totissue. Exemplary injection devices include specialized syringes,needles, and catheters that are compatible with a variety of scopedesigns (endoscope, laparoscope, etc.); the injection device may bedesigned with one needle or multiple needles (e.g., in a linear ornon-linear array) to simultaneously inject compositions into multiplesites. The kits may also include application devices for administeringfluid compositions onto tissue surfaces, for example, brushes, rollers,sprayers and catheter tubes that are compatible with a variety of scopedesigns (endoscope, laparoscope, etc.). In some embodiments, the kitincludes a catheter tube and syringe which can be coupled to thecatheter tube via a suitable fitting, such as a Luer fitting.

The kits may further contain a curing system such as a UV lamp or afiber optic which is coupled to a UV source or is configured to becoupled to be to a UV source. Such curing systems may be employed exvivo. Such curing systems may also be employed in vivo, in which casesuch systems can be made compatible with a variety of scope designs(endoscope, laparoscope, etc.).

The kits may include grafts, such as synthetic grafts, biologic graftsor combination synthetic/biologic grafts.

The kits may contain securement materials such as staples, suturematerials and/or adhesive compositions such as tissue adhesives. Thekits may also contain other devices designed to hold the composition inplace during cure.

The kits may contain one or more devices such as vaginal pessaries orinflatable devices (including inflatable pessaries) for support of thevaginal vault after surgery. The kits may contain one or more devicessuch as caps for maintaining the shape of the vaginal apex aftersurgery.

The kits may include instructions for administering the materialscontained in the kits (e.g., compositions for application onto tissue,compositions for injection into tissue, grafts, staples, sutures,adhesives, pessaries, caps, etc.). The kits may also include packagingand information as required by a governmental regulatory agency thatregulates pharmaceuticals and/or medical devices.

In certain embodiments, the components of the kits are provided in asterile package for convenient use by a health care professional. Incertain embodiments, the kits may provide the necessary components for asingle use, include various components selected from those describedabove, for example, combinations of two or more of the following: (a)one or more containers of an injectable composition as described herein,(b) one or more packages or containers of solid or solidifiablematerials as described herein, (c) one or more administration devices asdescribed herein (e.g., injection devices, catheters, sprayers, rollers,brushes, etc.), (d) a source of radiation (e.g., a UV lamp, fiber opticcable, etc.), (e) a vaginal support device (e.g., a vaginal pessary,inflatable device, cap, etc.), (f) graft material, and (g) securementmaterial (e.g., sutures, staples, adhesives, etc.), among othercomponents.

In certain embodiments, the kits can contain biological or chemicaltherapeutic agents that can be loaded into the compositions on site.Alternatively, the practitioner can select biological or chemical agentsas appropriate for loading at the time of the procedure.

Although various embodiments are specifically illustrated and describedherein, it will be appreciated that modifications and variations of thepresent invention are covered by the above teachings and are within thepurview of any appended claims without departing from the spirit andintended scope of the invention. For example, the kits and compositionsof the present invention may be used in medical procedures other thanprocedures for remodeling ligaments, connective tissue, muscles andorgans (e.g., USL, vagina, uterus, etc.) of the pelvis, including otherligaments, connective tissue, muscles and organs throughout the body.Such compositions may be administered, for example, to the bladder(e.g., to address bladder cancer, interstitial cystitis, overactivebladder, etc.), rectum, and urethral and anal sphincters (e.g., toaddress incontinence, etc.), among many other applications.

The invention claimed is:
 1. A kit for performing a hysterectomyoperation, the kit comprising: a first composition selected from aninjectable pre-formed hydrogel, an injectable hydrogel precursor, and aninjectable plug, the first composition configured to be injected into atleast one uterosacral ligament inside of a body of a patient to promoteremodeling within the at least one uterosacral ligament; a secondcomposition having a solid polymeric composition in a form of a sheet orstrip, the second composition includes a therapeutic agent selected fromat least one of a growth factor or a wound healing agent, the secondcomposition configured to be applied to a surface of the at least oneuterosacral ligament to increase a strength of the at least oneuterosacral ligament; an injection device for administering the firstcomposition; an application device for applying the second composition;a curing system configured to be coupled to an ultra-violet (UV) source;and a graft configured to be attached to the at least one uterosacralligament.
 2. The kit of claim 1, wherein the first composition comprisesa therapeutic agent selected from a growth factor and/or a wound healingagent.
 3. The kit of claim 1, wherein the first composition is aninjectable preformed hydrogel or injectable hydrogel precursor.
 4. Thekit of claim 1, wherein the first composition comprises a hydrophilicpolymer selected from alkylene glycol homopolymers and copolymers,polyol homopolymers and copolymers, polyester homopolymers andcopolymers, acrylate homopolymers and copolymers, methacrylatehomopolymers and copolymers, acrylamide homopolymers and copolymers,polysaccharides, and amino acid based polymers.
 5. The kit of claim 1,wherein the first composition includes a crosslinked hydrophilic polymeror the first composition is an injectable composition including acrosslinkable hydrophilic polymer and a photoinitiator.
 6. The kit ofclaim 1, further comprising a securement material, wherein thesecurement material is a tissue adhesive selected from a cyanoacrylateglue and a fibrin glue, and wherein the graft is selected from abiologic graft, a synthetic graft, and a combination biologic-syntheticgraft.
 7. The kit of claim 1, further comprising a vaginal supportdevice, wherein the vaginal support device is selected from a pessaryand a vaginal cap.
 8. The kit of claim 1, wherein the injection deviceis at least one of a syringe, a needle, or a catheter compatible with ascope device.
 9. The kit of claim 8, wherein the scope device is atleast one of an endoscope, a laparoscope, a hysteroscope, or acystoscope.
 10. The kit of claim 1, wherein the application device is atleast one of a syringe, a needle, or a catheter compatible with a scopedevice.
 11. The kit of claim 10, wherein the scope device is at leastone of an endoscope, a laparoscope, a hysteroscope, or a cystoscope. 12.The kit of claim 1, wherein the graft is selected from a biologic graft,a synthetic graft, and a combination biologic-synthetic graft.
 13. Thekit of claim 1, wherein the first composition is configured to beinjected into a pelvic support tissue.
 14. The kit of claim 1, whereinthe first composition is configured to be injected into a pelvic supporttissue and is converted into a hydrogel in vivo.
 15. The kit of claim 1,wherein the first composition is converted into a hydrogel by exposureto the UV source.
 16. The kit of claim 1, wherein the first compositionincludes only the injectable plug.